ED nurses: What you document can make or break a malpractice lawsuit
Don’t miss important details when documenting
Several days after a nurse gave an intramuscular (IM) injection to a patient with a bee sting, the patient returned complaining of hip pain and was diagnosed with piriformis syndrome. She sued the ED and claimed that the nurse negligently gave the IM injection in her right hip.
However, a review of the nursing documentation showed that the injection was given in the left upper outer quadrant of the buttock, which resulted in a defense verdict.1
This is one example of how ED nursing documentation can make or break the outcome of a malpractice lawsuit, says Mary Ann Shea, JD, RN, a St. Louis-based medical/legal consultant and former ED nurse.
What you document also can affect patient care, says Kayleen L. Paul, RN, CEN, care center director for emergency, critical care, and trauma services at McKay-Dee Hospital Center in Ogden, UT. "Baseline assessments allow the next nurse to recognize when a patient’s condition has changed," she says.
Ask yourself this question, recommends Shea: Would someone who wasn’t present at the time of the treatment be able to understand what happened? "Thorough and complete documentation that follows the nursing process is essential to show appropriate treatment was given within the acceptable standards of care," she adds.
To improve your documentation, do the following:
• Use standardized forms.
"We chart by exception, with normals’ precisely defined and printed on the back of the sheet," says Paul. The ED’s forms also use checklist formats to make charting quicker and easier, she adds.
Using standardized charting also can eliminate unapproved abbreviations, adds Shea. "Creating one’s own language’ in order to save time does not consistently communicate the correct information," she says.
The Joint Commission on Accreditation of Healthcare Organizations has identified miscommunication as the most common reason for sentinel events that injure patients. "This transfer of information, known as a handoff’ in Joint Commission language, is a terrific opportunity to share information and prevent medical error," notes Patricia Iyer, RN, MSN, LNCC, president of Flemington, NJ-based Med League Support Services, a legal nurse consulting firm specializing in malpractice and personal injury cases.
At Sentara Virginia Beach General Hospital, ED nurses use a preprinted fax sheet for admitted patients to ensure that all relevant information is documented. "Handoffs of patient care always present a risk, especially in a very busy department where you never know what’s coming through the doors next," says Kathie Carlson, RN, MSN, CEN, ED nurse.
• Use computerized charting.
Currently, an Emergency Department Information System is being implemented at McKay-Dee’s ED with computerized charting, to improve speed and accuracy. "It will be great to not always be looking for the patient’s chart," Paul says. "The record will also be instantly electronically available to nurses on the units for admitted patients."
However, electronic charting should not replace verbal communication, cautions Paul. A copy of the nursing flow sheet is sent with the patient to the admitting unit, but a nurse-to-nurse phone call is also required. "The ED nurse speaks personally to the receiving nurse on the floor," she says.
This gives nurses a chance to ask questions, identify equipment or supplies that will be needed, and convey potential problems such as a non-English-speaking or hearing-impaired patient, says Paul. "It gives the receiving nurse a much clearer picture of the patient’s needs," she says. "This may necessitate a room change — for example, if the patient needs to be close to the nurses’ station."
• Give one-on-one inservices.
McKay Dee’s ED educator works one-on-one with new nurses to improve charting by describing a patient and asking nurses to chart appropriately, says Paul. "She has recently posted privacy-protected examples of excellent charting for sexual assault victims and for providers exposed to HIV-positive needlesticks," she says.
• Have nurses audit patient charts.
At McKay Dee, nurses are assigned to review a specific number of charts per month and report their findings at staff meetings, says Paul. "In addition, we have billers in the ED who see every patient chart," she says. "They have become very adept at identifying both high- and low-quality nursing documentation and often bring examples of both to the manager’s attention."
The auditors use checklists to look for specific items of documentation, such as baseline assessments, repeated vital signs, or reassessment of pain scores. "We usually do 10-20 charts a month," says Paul. "All nurses participate at one time or another."
In addition, the ED’s care manager audits several dozen charts a month for compliance with clinical protocols and regulatory requirements for transferred patients. Recently, chart audits revealed that a physician had described a laceration repair on a trauma patient, but the nursing notes made no mention of it. If the laceration had become infected, nurses wouldn’t know if it was prepped appropriately, says Paul. "Also, what if the patient was involved with litigation due to his accident? The obvious omission of the laceration could cast doubt on other facts documented in the chart," she says.
• Include details.
Nursing documentation often lacks sufficient detail to adequately convey exactly what was done, says Shea. For example, nurses may document an IM injection without specifying the site, or document that an IV was started but omit the type or size of the needle or the type of fluids infusing.
Failing to document follow-up assessment after a procedure or treatment is a common mistake, such as documenting medications a patient was given without recording your reassessment, says Shea. "Remember, if you didn’t chart it, you can’t prove you did it."
Nurses often fail to include sufficient detail to show the nursing process was followed, adds Shea. For example, if a patient reports chest pain, notifying the physician is the proper intervention, but if the nurse doesn’t document this step, it will be difficult to later prove that it was done, she explains.
"Often nurses document the complaint of chest pain but not that the physician was made aware of it," says Shea. "In addition, the nurse should document the time the physician examined the patient and any new orders received."
• Document times of assessment and procedures.
For patients at risk for falls, document the time of your periodic observations, advises Iyer. "Timing is very important: When the patient came in, when the patient was seen, and what was done at particular times, such as calling consultants or notifying the floor that the patient is ready for admission," she says.
If a patient claims that a delay in treatment caused injury or death, it’s difficult to prove otherwise if the time treatment was initiated isn’t documented, says Shea. "Timeliness of treatment in an ED setting is often an issue in a lawsuit," she notes. For example, the time of medication administration and treatment for a patient in respiratory distress is crucial to prevent further deterioration, stresses Shea. "The times must be included to clearly demonstrate that treatment was indeed implemented immediately upon arrival, rather than 15 minutes later."
If the patients allege that their outcome would have been better if treatment had started sooner, you’ll need proof that it was done immediately, says Shea. "Documentation in the medical record is almost always presumed to be more accurate than the patient’s account to the contrary," she adds.
Reference
- Taylor v. Cabell Huntington Hospital Inc., 2000 WL 935428 S.E.2d WV (July 10, 2000)(Reported in Regan Report on Nursing Law.)
Sources
For more information on improving ED nursing documentation, contact:
- Kathleen Carlson, RN, MSN, CEN, Emergency Department, Sentara Virginia Beach General Hospital, 1060 First Colonial Road, Virginia Beach, VA 23454. Telephone: (757) 395-8890. E-mail: [email protected].
- Patricia Iyer, MSN, RN, LNCC, President, Med League Support Services, 260 Route 202-31, Suite 200, Flemington, NJ 08822. Telephone: (908) 788-8227. Fax: (908) 806-4511. E-mail: [email protected]. Web: www.medleague.com.
- Kayleen L. Paul, RN, CEN, Care Center Director, Emergency, Critical Care, and Trauma Services, McKay-Dee Hospital Center, 4401 Harrison Blvd., Ogden, UT 84403. Telephone: (801) 387-7006. Fax: (801) 387-7038. E-mail: [email protected].
- Mary Ann Shea, JD, RN, Attorney at Law/Registered Nurse, P.O. Box 220013, St. Louis, MO 63122. Telephone: (314) 822-8220. Fax: (314) 966-0722. E-mail: [email protected].
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